Client safety information and medical form

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Your Name *

Email *

Contact phone number *

Date of birth *

Town where you live (or nearest one)? *

Emergency contact name *

Emergency contact number

COVID 19 related questions. Please TICK BOX if you can confirm. In the last 14 days:

I am NOT displaying any common COVID symptoms e.g. new continuous cough and/or high temperature, lack of taste/smell
No-one in my household has displayed COVID symptoms
I should NOT be isolating or shielding according to the current Scottish Government guidance

This information will be held for 21 days in accordance with the Test and Protect process and afterwards will be deleted.

I acknowledge and accept the risk of infection through joining others, even though it is outdoors and with special measures in place? *

Yes I acknowledge
No, I don't

Please list any relevant medical issues that may affect your time on the water *

If none please write none

If you carry any medicine, where do you keep it? *

If none please write none

Are you happy to receive occasional marketing email from me? *

Yes I am happy with this
No thanks

Privacy: Are you happy for photos, videos taken on the trip in which you appear to be used within promotional material on paper and online including social media. - PLEASE TICK  (copy) *

Yes I am happy with this
No thanks

DISCLAIMER Sea kayaking and its associated activities, carries risk of injury and in very rare cases, death. I declare, I am fit and healthy, to the best of my knowledge to take part in sea kayaking activities, and I have declared above any relevant medical information. *

Please read and add your initials to the box

Name